Ileo-Anal Reservoir (J-Pouch) Procedure

Question:

I have Ulcerative Colitis and have been told I need to have my colon removed. Someone told me about the ileo-anal pouch. What is this?

Answer:

History of the ileo-anal reservoir (IAR) procedure

Ileo-anal reservoir surgery was first discussed in the late 1970’s as an option for patients requiring removal of the large bowel due to either ulcerative colitis (UC) or familial adenomatous polyposis (FAP). The procedure was developed in England and Japan as an alternative to other surgical options such as a permanent ileostomy or Kock pouch. It has since become widely recognized and accepted as the “gold standard” for most patients presenting with these illnesses. Several reservoir types and names for the procedure have been used over the years (Pelvic Pouch Procedure, ileal pouch-anal anastomosis, J-pouch, S-pouch). For the purposes of this discussion, it will be referred to as the IAR (ileo-anal reservoir).

Who is a candidate for the procedure?

This surgical procedure is an option for most individuals with ulcerative colitis (UC) or familial adenomatous polyposis (FAP). The creation of the reservoir can involve multiple operations. A period of adjustment to the “normal” functioning of the completed reservoir is required. This may involve some minor lifestyle changes. Adaptation to the reservoir can take 6-12 months. Patient motivation will add to the success of the procedure.

In general, the IAR procedure is not considered an option for patients with Crohn’s disease or those who have poorly functioning anal sphincters. Patients with indeterminate colitis (where a definite diagnosis of either Crohn’s disease or ulcerative colitis cannot be made) may be candidates for the IAR, but the failure rate for the procedure is higher for those with indeterminate colitis than UC. Older patients may also have the operation, but may be considered poor candidates. Concerns with older patients include the potential for poor post-operative function of the reservoir (including incontinence) and complications during the operation. Your surgeon will review whther this surgery is appropriate for you.

What is involved in the ileo-anal reservoir (IAR) operation?

The IAR procedure requires one, two, or three operations (stages) to remove the large bowel and the rectum, and to create a new reservoir. Determining whether your IAR can be done in one, two or three stages is dependent upon:

how healthy you are at the time of your operation,

whether you have been on any medications that may increase your risk for complications (like steroids),

the surgeon’s judgement as to which procedure will work best for you, and

your underlying disease (UC, indeterminate colitis, or FAP).

For most people, the IAR is done in two stages.

If there are many stages to the iar procedure, what happens with each stage?

The following chart briefly describes the procedures that occur with each stage of surgery. Again, whether you are a candidate for a one, two, or three stage procedure is dependent upon many factors and should be discussed with your surgeon.

In all of the IAR staged procedures, the entire large bowel (colon) and rectum are removed, and the anus is preserved. This part of the surgery is called a colectomy. The new reservoir is made from the last portion of your small bowel, the terminal ileum. While several types of reservoir construction have been developed, the most popular reservoir design is the “J” pouch. Part of the terminal ileum is “looped” onto itself into the shape of a “J” to create the new reservoir. Once the new reservoir is constructed, it will be attached to the anus.

The differences between a 1, 2 or 3 stage procedure depends on when the new reservoir is constructed, and on whether the reservoir and anastomosis need to be “protected” for a period of time while healing occurs. This protection means a temporary ileostomy (ask your Enterostomal Therapy Nurse for a teaching booklet on ileostomies). An ileostomy will divert the stool away from the reservoir to an outside adhesive pouch, allowing the reservoir and anastomosis to heal. This temporary ileostomy is usually “taken-down” or closed approximately three months after the formation of the reservoir. The following diagram shows the specific procedures involved in each stage of a 1, 2 or 3 stage IAR procedure.

Will I need to have a stoma if I have the IAR Procedure?

If you are having the IAR constructed over more than one operation, then you will require a temporary stoma (ileostomy). The ileostomy will prevent stool from entering the reservoir while it is healing.

How long will I need to have the stoma?

If the IAR is being constructed over two operations, the usual time interval between each operation is 3 months. If the IAR is being constructed over three operations, then you will need a temporary ileostomy between each stage. The interval between colectomy (removal of the large colon and rectum) and the IAR operation is at least 4-6 months. This time will allow you to be in the best health before having the operation for the IAR.

If I have more than one operation, will I be able to return to work/school between each operation?

There is no definite answer to this. It depends upon how ill you were prior to your first operation, how well you recuperated from your operation, and the type of work/schooling that you are doing. If you would like to return to work or school before your next operation, this should be discussed with your surgeon.

What can I expect after all of the operations are completed?

Stool consistency: Once all of the stages of the IAR have been completed, your stool will initially be quite liquid. As you resume a normal diet, the stool should thicken and become pasty in consistency. The time interval from liquid to pasty stool can be from days to a few weeks. Your stool should be soft/pasty, but you may experience occasional times when it is more liquid due to certain foods or beverages that you have consumed. Some patients may tend to have more liquid stools. You will probably never have a formed, solid stool.

Stool frequency: At the beginning, the reservoir capacity can be quite small (less than a cup) and the stool tends to be more liquid. Liquid stool is harder to retain, or to “hold on to.” As a result, you may have many bowel movements in a 24 hour period, sometimes as many as 10 to 15. This includes night-time bowel movements. As the stool thickens, you will be able to comfortably delay the bowel movements and hold on to a larger volume. For most people, the frequency of the bowel movements will usually settle between 4-8 per day. Reservoir function continues to improve over 6-12 months.

Peri-anal skin protection: The frequency of your bowel movements can be quite high, especially at the beginning, causing irritation and itchiness to the skin around the anus (peri-anal skin). You will be taught how to protect the peri-anal skin, preventing any irritation. It is best to start protecting your peri-anal skin with the first bowel movement after surgery. Do not wait for irritation to develop. Pamphlets are available which describe peri-anal skin care techniques to follow.

Differentiating between gas and stool in the reservoir: Initially, most people with an IAR find it difficult to tell if the reservoir is filled with gas or with stool. For the first few months after your final operation, you should always assume that the reservoir is filled with stool. Sit on the toilet to pass the contents of the reservoir. Over time, most patients are able to regain the ability to tell the difference between gas and stool.

Reservoir gas: Once you have returned to a normal diet, you may experience times of large amounts of gas in the reservoir. This can cause bloating and sometimes explosive gas when sitting on the toilet. To help control this, avoid foods that cause gas. You can also try over-the-counter products such as Beano™ or Gas-Ex™, which may decrease the amount of gas produced by certain foods. You can also discuss dietary changes with your dietitian.

Emptying the reservoir: You may have a sense of fullness or pressure in your lower abdomen when your reservoir needs to be emptied. At the beginning, while your reservoir is small and the stool is liquid, you may not get much warning that you need to go to the bathroom (urgency). Gradually, your stool will thicken and your reservoir will expand. You will be able to delay the bowel movements and to comfortably get to a bathroom without any urgency. When you do sit on the toilet to empty your reservoir, you may find that it will not empty completely right away. You may need to sit for a few minutes to allow it to empty. You may want to rock from side to side while sitting on the toilet, or stand briefly to “shift” the contents of the reservoir. Gently “bearing down” will also help to empty the reservoir.

Night-time stools: Many patients with an IAR will need to get up during the night at least once to empty his/her reservoir. This tends to happen more during the early months of reservoir functioning. If you find that you are waking up at night because you need to empty your reservoir frequently, you may want to make some changes to your diet. Try to eat your largest meal at lunch and not at dinner time. Try to avoid eating large amounts of food 4-6 hours before you go to bed. Try to avoid drinking large amounts of fluid (especially caffeinated or carbonated drinks) in the evening. Remember to empty the reservoir just before going to bed. You can discuss strategies to manage night-time stools with your dietitian.

Diet: You will be able to return to a normal diet after your operation. Certain foods or drinks may cause looser or thicker stools, more gas, or more peri-anal skin irritation. The table below lists some common responses to different foods and drinks. You may also find that changes will occur to your bowel function with foods not listed in the table. Having increased gas or looser stools does not mean that you have to avoid these foods. You should just be aware of the possible change in bowel function when you eat/drink these items.

Further implications of the IAR procedure, such as the impact on stool consistency and frequency, diet changes and possible short and long-term complications are discussed in the article Ileo-Anal Reservoir Complications.

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